Remote Senior Manager Health Plan Claims Audit Readiness

Mosaic Health, LLC.; California; Remote; USD 130,000 - 195,000; Full time

Benefits offered by this job

3 weeks PTO

8 paid holidays

Medical, Dental, Vision

401(k) with match

Wellness programs

Employee discounts

Job summary

Mosaic Health, LLC. is seeking a Senior Manager, Claims Health Plan Readiness to lead regulatory compliance and CMS audits for health plans.

The role oversees claims adjudication, audit preparation, and corrective actions, partnering with Compliance, Finance, IT, and Clinical Operations to strengthen controls and improve performance. The position is fully remote, aligns with Pacific Time business hours, and requires extensive CMS knowledge and leadership experience in health plan environments.

Qualifications

• Bachelor's degree or equivalent experience in a related field.
• 8–10+ years in healthcare claims, adjudication, reimbursement, or regulatory compliance.
• 3–5+ years of leadership experience managing teams or cross-functional programs.
• Extensive knowledge of CMS requirements and health plan regulatory compliance including coding standards.

Responsibilities

• Develop and govern claims health plan readiness with CMS and health plan audits as core priorities.
• Lead multiple teams to support compliant claims adjudication, reimbursement accuracy and audit readiness.
• Coordinate CMS audits, prepare documentation, evidence, responses, and corrective actions.
• Translate regulatory changes into scalable policies and operating procedures.
• Direct analysis and remediation of adjudication errors, denials, and payment discrepancies.
• Sponsor system and workflow improvements for payment integrity and coding controls.
• Establish metrics to monitor audit readiness and communicate risks to senior leadership.
• Provide leadership across Compliance, Finance, IT, Clinical Operations, Provider Relations, and Payment Integrity.

Skills

CMS regulations

Regulatory compliance

Audits leadership

Healthcare claims

Cross-functional leadership

Analytics

Education

Bachelor's degree

Tools

Facets

QNXT

EDI 837/835

Claims systems

Coding (ICD-10-CM, CPT, HCPCS)

Job description

Mosaic Health, LLC. is seeking a Senior Manager, Claims Health Plan Readiness to lead regulatory compliance and CMS audits for health plans.

The role oversees claims adjudication, audit preparation, and corrective actions, partnering with Compliance, Finance, IT, and Clinical Operations to strengthen controls and improve performance. The position is fully remote, aligns with Pacific Time business hours, and requires extensive CMS knowledge and leadership experience in health plan environments.